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PSORIASIS

Introduction

Psoriasis is a chronic inflammatory skin disease caused by increased epidermal proliferation and characterized by scaly papules and plaques that can affect any part of the body. It can be seen throughout the upper extremities, but early changes are common over the olecranon and posterior elbow, as well as the thenar and hypothenar areas. Palmoplantar psoriasis is a variant of the disease that characteristically affects the skin of the palms and soles. This variant accounts for 3-4% of all psoriasis cases and features hyperkeratotic, pustular, or mixed morphologies.1-5

Pathophysiology

  • Although psoriasis appears to be caused by a combination of genetic, environmental, and immune-mediated components, its pathogenesis is not completely understood. Multiple theories exist regarding triggers of the disease process, but in many patients, no obvious trigger can be identified. Once triggered, however, there appears to be substantial leukocyte recruitment to the dermis and epidermis that results in the characteristic psoriatic plaques.1,2
  • The genetic basis of psoriasis is supported by family-based investigations, population-based epidemiologic studies, genome-wide linkage scans, and twin studies. This research has shown that ~35% of psoriasis patients have a family history of the disease, and that it occurs concurrently in ~80% of identical twins. The most common genetic factor associated with palmoplantar psoriasis specifically is the human leukocyte antigen Cw6.2,5
  • Environmental triggers for psoriasis include smoking, irritants, friction, and manual or repetitive trauma. Paradoxically, anti-tumor necrosis factor-alpha agents have been shown to induce palmoplantar eruptions. Smoking is believed to initiate psoriasis through oxidative, inflammatory, and genetic mechanisms.1,2

Related Anatomy

  • Epidermis
  • Dermis
  • Basal epidermal layer
  • Palmoplantar skin
  • Keratinocytes
  • Stratum corneum

Incidence and Related Conditions

  • Psoriasis affects approximately 1-2.2% of the U.S. population, with about 250,000 new cases being reported each year.6
  • Palmoplantar psoriasis has been found to account for 3-4% of all psoriasis cases.1,2
  • Psoriasis can occur at any age, but the median age at onset is 28 years, and it has a bimodal peak between ages 20-30 and 50-60. Psoriasis generally appears to be slightly more prevalent in women than men, but gender specificity is not clear in palmoplantar psoriasis.2
  • Palmoplantar pustulosis
  • Psoriatic arthritis
  • Acrodermatitis continua of Hallopeau

Differential Diagnosis

  • Acquired palmoplantar keratoderma 
  • Contact dermatitis
  • Candidiasis
  • Dyshidrotic eczema
  • Intertrigo 
  • Pityriasis rubra pilaris
  • Tinea cruris
  • Tinea pedis/manuum 
ICD-10 Codes

  • SKIN - COMMON HAND RASHES: PSORIASIS

    Diagnostic Guide Name

    SKIN - COMMON HAND RASHES: PSORIASIS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PSORIASISL40.9   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Psoriasis of the Upper Extremity
  • Psoriasis of the posterior upper arm and posterior right chest
    Psoriasis of the posterior upper arm and posterior right chest
Symptoms
Lesions surrounded by erythematous scales (built up stratum corneum)
Joint pain and swelling
Rash, pustules and pruritus
Dystrophic nails
Painful fissures seen as thick, scaly, hyperkeratotic plaques
Typical History

The typical patient is a 28-year-old woman who is a frequent smoker and has a family history of psoriasis. A few months ago, she began observing small lesions gradually developing on the palms of her hands and soles of her feet. Over time, these lesions grew into well-demarcated, erythematous, scaly plaques, and were accompanied by pustules, nail thickening, and painful fissures. The progression of her symptoms eventually began to interfere with her ability to complete daily activities, which led her to consult with a dermatologist.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the diagnosis accurately
  • Successful treat the lesion
Conservative

The goal of psoriasis treatment is to decrease the epidermal proliferation of the underlying dermal inflammation. 1,2,4,5

  • Palmoplantar psoriasis, specifically, has been a historically difficult condition to treat. No standardized treatments have been established, so management decisions should be made individually based on age, sex, occupation, the general health and functional impairments of the patient, and disease characteristics.1,2,4
  • Topical therapy
    • Corticosteroids
      • Used as a first-line agent in about 80% of the patients with palmoplantar psoriasis, often for up to 6-8 weeks or longer. 
      • May be combined with other agents, such as vitamin D analogs, calcineurin inhibitors, systemic drugs, or phototherapy.1
  • Salicylic acid
  • Tars 
  • Calcipotriene
  • Emollients
  • Systemic therapy
    • Biologic agents, including anti-TNF, anti-IL-12, anti-IL-17, and anti-IL-23 agents
    • Retinoids
      • Systemic treatment of choice (especially acitretin) for palmoplantar psoriasis, except for in women of childbearing age.1
      • Methotrexate
      • Cyclosporine
      • Phototherapy (in particular, narrow band UVB therapy or Excimer laser)
        • May be prescribed independently orconcomitantly with topical steroids, systemic retinoids, or methotrexate.1
Operative

No specific surgical interventions are available or indicated for psoriasis patients.

Complications
  • Secondary infections
  • Psoriatic arthritis
Outcomes
  • Despite the impact of palmoplantar psoriasis, few clinical studies have been conducted that address treatment, and there is a lack of data and quality-of-life assessment beyond anecdotal case reports and small studies evaluating a few select interventions.4
  • Meta-analytic reviews have shown that 12 weeks of oral retinoid therapy led to resolution of palmoplantar psoriasisin 39% of patients, and pustulation and hyperkeratosis also decreased in most cases.1
Key Educational Points
  • Many patients note that their psoriasis is better in the summer and worse in the winter, which may be due to a favorable effect of sunlight.5
  • Although psoriasis was first clinically described in the 1800s, the formal classification of psoriasis phenotypes has only recently been explored and better defined.4
  • The patient history should include a thorough exploration of potential triggers and exposures that may be related to the disease.
  • The skin exam will show erythematous skin with demarcated inflamed papules, patches, and plaques.5
  • Palmoplantar Psoriasis Area and Severity Index (PPASI) is useful for identifying and monitoring palmoplantar psoriasis.2
  • A biopsy is often needed if palmoplantar psoriasis is suspected to distinguish it from eczematous hand dermatitides and to rule out tinea.2
  • Potassium hydroxide preparation should be performed for any scaly erythematous eruption on the palms and soles to rule out dermatophytes.2
  • Palmoplantar psoriasis creates a much more disabling condition than psoriasis without palm and sole involvement, often having a negative impact on patients’ quality of life.1
  • Systemic steroids should be avoided when treating psoriasis patients. While they may produce immediate resolution of disease, this can be followed by generalization of psoriasis, including progression to pustular variants.
References

New and Cited Articles

  1. Engin B, Askin O, Tuzun Y. Palmoplantar psoriasis. Clin Dermatol 2017;35(1):19-27. PMID: 27938808
  2. Miceli A, Schmieder GJ. Palmoplantar Psoriasis. In: StatPearls.Treasure Island (FL) 2019. PMID: 28846363
  3. Sanchez IM, Sorenson E, Levin E, Liao W. The Efficacy of Biologic Therapy for the Management of Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review. Dermatol Ther (Heidelb) 2017;7(4):425-446.PMID: 29143230
  4. Farley E, Masrour S, McKey J, Menter A. Palmoplantar psoriasis: a phenotypical and clinical review with introduction of a new quality-of-life assessment tool. J Am Acad Dermatol 2009;60(6):1024-1031.PMID: 19467374
  5. Marks JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. Fifth Ed. London, New York: Saunders Elsevier; 2013.
  6. Bhosle MJ, Kulkarni A, Feldman SR, Balkrishnan R. Quality of life in patients with psoriasis. Health Qual Life Outcomes 2006;4:35.PMID: 16756666
  7. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin.12thEd. Philadelphia, PA. Elsevier, 2016.

Reviews

  1. Sanchez IM, Sorenson E, Levin E, Liao W. The Efficacy of Biologic Therapy for the Management of Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review. Dermatol Ther (Heidelb) 2017;7(4):425-446.PMID: 29143230
  2. Raposo I, Torres T. Palmoplantar Psoriasis and Palmoplantar Pustulosis: Current Treatment and Future Prospects. Am J Clin Dermatol2016;17(4):349-58. PMID: 27113059
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